3. HEMORRAGIA DIGESTIVA BAJAHEMORRAGIA DIGESTIVA BAJA
HDBHDB
SANGRADO POR DEBAJO DEL
ANGULO DE TREITZ
EPIDEMIOLOGIA:
Incidencia: 20,5-27 x 100,000 Hab.
Incrementa con la edad
10 - 24 % de todos los episodios
de sangrado
4. CASO CLINICO
Mujer de 76 años que acude por presentar
deposiciones sanguinolentas abundantes (> 1
lt) hace 2 horas, sus familiares la encontraron
desmayada y la trajeron inmediatamente al
hospital
No tiene antecedentes patologicos de
importancia
PA: 50/0 FC: 120 x min
Palidez importante de piel y mucosas.
9. CAUSAS DE HDB EN EL PERU
DIVERTICULOS DE COLON 50,4%
FIEBRE TIFOIDEA 8,8%
HEMORROIDES INTERNAS 5,9%
ANGIODISPLASIA DEL COLON 3,7%
CANCER DE COLON 2,9%
OTROS 32,0%
HNERM LIMA
11. Afecta mas a poblacion geriatrica
Complicacion (3%) de los pacientes que
sufren diverticulosis
Preponderante en colon sigmoides
Hematoquezia masiva
No hay dolor abdominal
21. ANGIODISPLASIA O ECTASIA
VASCULAR
Mayor frecuencia en poblacion geriatrica
Las lesiones suelen ser multiples y pequeñas (< 5 mm) y se
ubican preferentemente en hemicolon derecho y ciego
Se relacionan con enfermedad aortica (?)
38. INVESTIGACION CLINICA
REANIMACION
HISTORIA CLINICA Y EXPLORACION
FISICA
ENDOSCOPIA
ENDOSCOPIA DIGESTIVA ALTA
COLONOSCOPIA
GAMMAGRAFIA CON GR TC99
ANGIOGRAFIA MESENTERICA
39. HDB – TRATAMIENTO
CONSIDERACIONES GENERALES:
Las mismas que en HDA
CONSIDERACIONES ESPECIFICAS:
60% dejan de sangrar en las 48 hs, 20% cesa la hemorragia pero
se reanuda a las 48-72 hs, 20% continuan sangrando
1. Si continua sangrando y necesita mas de 2 unidades de sangre
c/8 hs por 24 hs debe considerarse cirugia de emergencia con
o sin diagnostico etiologico
2. Si vuelve a sangrar luego de 48-72 hs de haber cesado,
compensar hemodinamicamente y luego pasar a cirugia.
3. Si ceso el sangrado, pero no tenemos diagnostico etiologico,
re-evaluar con estudios diagnosticos adecuados o repetirlos.
40. TRATAMIENTO DE LA HDB
REANIMACION
MEDICACION ESPECIFICA
ENDOSCOPIA TERAPEUTICA
ANGIOGRAFIA TERAPEUTICA
INTERVENCION QUIRURGICA
41. HEMORRAGIA DIGESTIVA BAJA
Estimar volumen de la perdida sanguinea
Hb,Hto, Hem, Pruebas de coagulacion, GS y rH
Via central, PVC,
Sonda Foley (volumen urinario)
PROCTOSIGMOIDOSCOPIA
NEGATIVA
TRATAMIENTO
POSITIVA
SNG – ENDOSCOPIA
DIGESTIVA ALTA
NEGATIVA
CESO LA
HEMORRAGIA
DIGESTIVA
CONTINUA LA
HEMORRAGIA
DIGESTIVA
42. HEMORRAGIA DIGESTIVA BAJA
MASIVO
COLONOSCOPIA
Rx DE COLON
ARTERIOGRAFIA
SCAN CON TC99
LENTO
CESO LA
HEMORRAGIA
DIGESTIVA
CONTINUA LA
HEMORRAGIA
DIGESTIVA
POSITIVA NEGATIVA
TRATAMIENTO
ARTERIOGRAFIA
POSITIVA NEGATIVA
RE-EVALUACION
TRATAMIENTO
QUIRURGICO
POSITIVO NEGATIVO
TRATAMIENTO CIRUGIA
COLONOSCOPIA
INTRAOPERATO
RIA
Notas del editor
Figure 7-20. Most bleeding from colorectal polyps and cancer is occult or mild and intermittent. Rarely polyps and cancer may cause significant lower gastrointestinal hemorrhage. Left-sided and rectal neoplasms are more likely to cause gross bleeding than right-sided lesions. Diagnosis is made by endoscopy or barium enema. Treatment for bleeding polyps or cancer is usually by colonoscopic removal or surgery. This figure depicts a pedunculated sigmoid polyp (A). A descending colon adenocarcinoma (B) and an annular rectal adenocarcinoma (C) are also shown. (A, Courtesy of J. Lappas, Indianapolis, IN)
Figure 7-20. Most bleeding from colorectal polyps and cancer is occult or mild and intermittent. Rarely polyps and cancer may cause significant lower gastrointestinal hemorrhage. Left-sided and rectal neoplasms are more likely to cause gross bleeding than right-sided lesions. Diagnosis is made by endoscopy or barium enema. Treatment for bleeding polyps or cancer is usually by colonoscopic removal or surgery. This figure depicts a pedunculated sigmoid polyp (A). A descending colon adenocarcinoma (B) and an annular rectal adenocarcinoma (C) are also shown. (A, Courtesy of J. Lappas, Indianapolis, IN)
Figure 7-14. Angiodysplasia are the most frequently encountered vascular abnormalities of the gastrointestinal tract and are a common etiology of lower gastrointestinal bleeding [14]. In patients with lower gastrointestinal bleeding, the prevalence of angiodysplasia ranges from 6% to 30%. Colonic angiodysplasia are more commonly found in the cecum and ascending colon. Pictured is the distribution of colonic angiodysplasia in one series of 59 patients. Multiple lesions are seen in 40% to 75% of patients. Bleeding is usually subacute and recurrent, but 15% of patients present with massive hemorrhage. In 90% of cases, bleeding stops spontaneously. With the advent of colonoscopy, angiodysplasia are often found in persons without evidence of bleeding. Of 964 asymptomatic patients undergoing colonoscopy for colorectal cancer screening, Foutch [19] found the prevalence of angiodysplasia to be 0.93%. (From Hochter et al. [20]; with permission.) References: [14]. Reinus JF, Brandt LJ, Vascular ectasias and diverticulosis. Common causes of lower intestinal bleeding. Gastroenterol Clin North Am 1994 23 1-20 [19]. Foutch PG, Angiodysplasia of the gastrointestinal tract. Am J Gastroenterol 1993 88 807-818 [20]. Hochter W, Weingart J, Kuhner W, et al. Angiodysplasia in the colon and rectum. Endoscopic morphology, localization, and frequency. Endoscopy 1985 17 182-185
Figure 7-15. Colonic angiodysplasia are thought to be acquired and associated with aging. Boley et al. [21] proposed that repeated intermittent low-grade obstruction of submucosal veins at the point where they crossed colonic muscle layers led to the development of angiodysplasia. A normal vein perforating the muscular layer is shown (A). The vein is partially obstructed because of muscular contraction or increased intraluminal pressure (B). Over a period of years, the submucosal vein becomes dilated and tortuous (C), the veins and venules draining into the submucosal vein become dilated (D), and the capillary ring becomes dilated, the precapillary sphincter becomes incompetent, and a small arteriovenous communication arises (E). Boley et al. [21] proposed that angiodysplasia were more prevalent in the right colon because of the increased diameter and wall tension. The factors responsible for the initiation of bleeding are unknown. (From Boley et al. [21]; with permission.) References: [21]. Boley SJ, Sammartano R, Adams A, On the nature and etiology of vascular ectasias of the colon. Degenerative lesions of aging. Gastroenterology 1977 72 650-660
Figure 7-16. Colonoscopy detects approximately 80% of colonic angiodysplasia. Lesions appear flat or slightly raised, red, and 2 to 10 mm in diameter. They may be round, stellate, or fernlike [19]. There may be a prominent feeding vessel or a pale mucosal halo (A-D). Many lesions may mimic angiodysplasia, including lesions of hereditary hemorrhagic telangiectasia, ischemia, radiation colitis, and suction artifacts. Lesions may be missed if the patient is anemic or volume depleted. The effect of narcotics on the endoscopic appearance of angiodysplasia is controversial. Narcotics may lead to vasoconstriction and decreased mucosal blood flow, thus obscuring angiodysplasia, whereas naloxone hydrochloride may act to reverse these vasoconstrictive effects [22]. References: [19]. Foutch PG, Angiodysplasia of the gastrointestinal tract. Am J Gastroenterol 1993 88 807-818 [22]. Deal SE, Zfass AM, Duckworth PF, et al. Arteriovenous malformation (AVMs). Are they concealed by meperidine [Abstract]? Am J Gastroenterol 1991 86 1351-1351
Figure 7-16. Colonoscopy detects approximately 80% of colonic angiodysplasia. Lesions appear flat or slightly raised, red, and 2 to 10 mm in diameter. They may be round, stellate, or fernlike [19]. There may be a prominent feeding vessel or a pale mucosal halo (A-D). Many lesions may mimic angiodysplasia, including lesions of hereditary hemorrhagic telangiectasia, ischemia, radiation colitis, and suction artifacts. Lesions may be missed if the patient is anemic or volume depleted. The effect of narcotics on the endoscopic appearance of angiodysplasia is controversial. Narcotics may lead to vasoconstriction and decreased mucosal blood flow, thus obscuring angiodysplasia, whereas naloxone hydrochloride may act to reverse these vasoconstrictive effects [22]. References: [19]. Foutch PG, Angiodysplasia of the gastrointestinal tract. Am J Gastroenterol 1993 88 807-818 [22]. Deal SE, Zfass AM, Duckworth PF, et al. Arteriovenous malformation (AVMs). Are they concealed by meperidine [Abstract]? Am J Gastroenterol 1991 86 1351-1351
Figure 7-16. Colonoscopy detects approximately 80% of colonic angiodysplasia. Lesions appear flat or slightly raised, red, and 2 to 10 mm in diameter. They may be round, stellate, or fernlike [19]. There may be a prominent feeding vessel or a pale mucosal halo (A-D). Many lesions may mimic angiodysplasia, including lesions of hereditary hemorrhagic telangiectasia, ischemia, radiation colitis, and suction artifacts. Lesions may be missed if the patient is anemic or volume depleted. The effect of narcotics on the endoscopic appearance of angiodysplasia is controversial. Narcotics may lead to vasoconstriction and decreased mucosal blood flow, thus obscuring angiodysplasia, whereas naloxone hydrochloride may act to reverse these vasoconstrictive effects [22]. References: [19]. Foutch PG, Angiodysplasia of the gastrointestinal tract. Am J Gastroenterol 1993 88 807-818 [22]. Deal SE, Zfass AM, Duckworth PF, et al. Arteriovenous malformation (AVMs). Are they concealed by meperidine [Abstract]? Am J Gastroenterol 1991 86 1351-1351
Figure 7-16. Colonoscopy detects approximately 80% of colonic angiodysplasia. Lesions appear flat or slightly raised, red, and 2 to 10 mm in diameter. They may be round, stellate, or fernlike [19]. There may be a prominent feeding vessel or a pale mucosal halo (A-D). Many lesions may mimic angiodysplasia, including lesions of hereditary hemorrhagic telangiectasia, ischemia, radiation colitis, and suction artifacts. Lesions may be missed if the patient is anemic or volume depleted. The effect of narcotics on the endoscopic appearance of angiodysplasia is controversial. Narcotics may lead to vasoconstriction and decreased mucosal blood flow, thus obscuring angiodysplasia, whereas naloxone hydrochloride may act to reverse these vasoconstrictive effects [22]. References: [19]. Foutch PG, Angiodysplasia of the gastrointestinal tract. Am J Gastroenterol 1993 88 807-818 [22]. Deal SE, Zfass AM, Duckworth PF, et al. Arteriovenous malformation (AVMs). Are they concealed by meperidine [Abstract]? Am J Gastroenterol 1991 86 1351-1351
Figure 7-17. The diagnostic yield of angiography for angiodysplasia is 17% to 20%. Classic findings include late draining veins (85% to 90%) representing obstructed submucosal veins (A), vascular tufts (70% to 75%) (B), early filling veins (60% to 80%) indicative of arteriovenous communication (C), and extravasation of contrast (6% to 20%) (not pictured) [19]. (Courtesey of N. Harris, Indianapolis, IN) References: [19]. Foutch PG, Angiodysplasia of the gastrointestinal tract. Am J Gastroenterol 1993 88 807-818
Figure 7-17. The diagnostic yield of angiography for angiodysplasia is 17% to 20%. Classic findings include late draining veins (85% to 90%) representing obstructed submucosal veins (A), vascular tufts (70% to 75%) (B), early filling veins (60% to 80%) indicative of arteriovenous communication (C), and extravasation of contrast (6% to 20%) (not pictured) [19]. (Courtesey of N. Harris, Indianapolis, IN) References: [19]. Foutch PG, Angiodysplasia of the gastrointestinal tract. Am J Gastroenterol 1993 88 807-818
Figure 7-17. The diagnostic yield of angiography for angiodysplasia is 17% to 20%. Classic findings include late draining veins (85% to 90%) representing obstructed submucosal veins (A), vascular tufts (70% to 75%) (B), early filling veins (60% to 80%) indicative of arteriovenous communication (C), and extravasation of contrast (6% to 20%) (not pictured) [19]. (Courtesey of N. Harris, Indianapolis, IN) References: [19]. Foutch PG, Angiodysplasia of the gastrointestinal tract. Am J Gastroenterol 1993 88 807-818
Figure 7-23. Most patients with ischemic colitis present with abdominal pain, however, 15% to 25% of patients may present with overt rectal bleeding. Complete absence of bleeding, including occult bleeding, is uncommon. Bleeding is occasionally massive. Endoscopy is the diagnostic procedure of choice. Endoscopically, rectal sparing is typical because of the middle rectal artery collateral circulation. Ischemic proctitis has primarily been reported in patients with extensive pelvic surgery and presumed disruption of rectal blood flow. A, The mucosa may be pale, edematous, and friable in early disease. B and C, The mucosa may also show a blue-black discoloration signifying mucosal necrosis and submucosal hemorrhage if the disease is extensive. The areas most commonly affected are the watershed areas of the splenic flexure and sigmoid colon, which are at the periphery of the inferior mesenteric artery circulation. Most patients with ischemic colitis have a self-limited course with spontaneous recovery. However, transmural necrosis and peritonitis may develop, and this possibility necessitates careful clinical observation. In some cases, healing may occur with subsequent stricture formation. (A, Courtesy of D. Johnson, Norfolk, VA) (B and C, Courtesy of R. Goulet, Indianapolis, IN)
Figure 7-23. Most patients with ischemic colitis present with abdominal pain, however, 15% to 25% of patients may present with overt rectal bleeding. Complete absence of bleeding, including occult bleeding, is uncommon. Bleeding is occasionally massive. Endoscopy is the diagnostic procedure of choice. Endoscopically, rectal sparing is typical because of the middle rectal artery collateral circulation. Ischemic proctitis has primarily been reported in patients with extensive pelvic surgery and presumed disruption of rectal blood flow. A, The mucosa may be pale, edematous, and friable in early disease. B and C, The mucosa may also show a blue-black discoloration signifying mucosal necrosis and submucosal hemorrhage if the disease is extensive. The areas most commonly affected are the watershed areas of the splenic flexure and sigmoid colon, which are at the periphery of the inferior mesenteric artery circulation. Most patients with ischemic colitis have a self-limited course with spontaneous recovery. However, transmural necrosis and peritonitis may develop, and this possibility necessitates careful clinical observation. In some cases, healing may occur with subsequent stricture formation. (A, Courtesy of D. Johnson, Norfolk, VA) (B and C, Courtesy of R. Goulet, Indianapolis, IN)
Figure 7-27. Approximately 2% to 5% of patients receiving radiation therapy for gynecologic, prostate, bladder, or rectal cancer will develop chronic radiation injury to the rectum and sigmoid colon. The extent and severity of the injury depends on the total dose of radiation and the volume of the bowel exposed. The pathogenesis of the injury is believed to involve radiation-induced vascular changes of the bowel wall with resultant tissue ischemia. Because of its fixed position in the pelvis, the rectum is damaged in 70% to 90% of all patients with intestinal radiation injuries. Patients usually present with intermittent rectal bleeding, tenesmus, and altered bowel habits. The bleeding may be slow, resulting in iron deficiency anemia, or occasionally, massive. A and B, Endoscopically there is mucosal erythema, edema, friability, and diffuse telangiectasias. An effective therapy for hemorrhage from radiation proctitis is endoscopic laser ablation or electrocautery of telangiectasias. Decreased transfusion requirements can be achieved using the Nd:YAG (neodymium:yttrium-aluminum-garnet) laser or argon laser. Medical therapy of radiation proctitis has met with limited success. Oral or rectal steroids and sulfasalazine, sucralfate enemas, intrarectal formalin, and hyperbaric oxygen have all been used, but no controlled trials of these modalities have been performed. Surgery is seldom used for radiation injury because of a substantial risk of complications.
Figure 7-28. Inflammatory bowel disease is a common cause of lower gastrointestinal bleeding in the younger patient. Rectal bleeding is a common manifestation of ulcerative colitis. Patients with Crohn's disease usually present with abdominal pain and diarrhea but may have bleeding. Bleeding in inflammatory bowel disease is usually recurrent and minor. Profuse bleeding develops in up to 6% of patients with ulcerative colitis or Crohn's disease. Robert et al. [41] evaluated 21 patients with Crohn's disease and severe gastrointestinal hemorrhage. They found that 66% of the patients had ileocolitis, 19% had entries alone, and 14% had colitis alone. The bleeding stopped spontaneously in 50% of the patients, but 33% had rebleeding. The authors advocated early surgical intervention in patients who have a high rebleeding rate. A, An endoscopic view of severe Crohn's colitis. B, Enteroclysis revealed terminal ileum involvement of Crohn's disease. C, A positive bleeding scan in a patient with Crohn's disease. D, Surgical resection specimen from a patient with Crohn's disease and severe bleeding. (B and C, Courtesy of J. Lappas, Indianapolis, IN) (D, Courtesy of R. Goulet, Indianapolis, IN) References: [41]. Robert JR, Sachar DB, Greenstein AJ, et al. Severe gastrointestinal hemorrhage in Crohn's disease. Ann Surg 1991 213 207-211